Clinical hopes and public fears in forensic mental health

Forensic mental health services are charged with two potentially conflicting tasks: public protection and ethical patient care. The challenge to fulfil these dual roles is most acute when considering the prolonged detention of patients who have been acquitted of serious violent offences on grounds of insanity, or found unfit to stand trial. The duration of their hospital stay often far exceeds that required to treat the most acute manifestations of their illness. Despite this, it is often argued that the seriousness of the offence should not be taken into account when determining duration of hospitalization. This paper argues that risk assessment is a complex process, involving consideration of many factors in addition to acute symptomatology. All such assessments carry an inherent level of uncertainty, which can be minimized by lengthy rehabilitation and assertive community care. It is argued that authorities are justified in considering the seriousness of the index offence when making judgements as to what level of uncertainty in risk assessment can be considered acceptable in the long term management of forensic patients. The implications of this for services, legislators and politicians are discussed.